Our meta-analysis encompassing a representative sample of patients and physician users has shown that ultrasound-based estimates of CVP are moderately correlated with invasive measures. In an undifferentiated population, the IVC diameter is the most highly correlated, followed by E/Ep, and lastly IVC collapsibility. The IVC diameter was similarly correlated in ventilated and non-ventilated patients, while the other parameters performed less well in ventilated patients. Given these findings, and the relative ease of measuring the IVC diameter, it is reasonable to utilize IVC diameter as the starting point to determine volume status if invasive monitoring is not warranted or available.
The findings of our meta-analysis demonstrate that the tricuspid E/Ep ratio is a promising parameter. E/Ep performed with moderate correlation in the non-ventilated group of patients. The performance of this test in mechanically ventilated group remains an unknown due the inclusion of only 2 studies in this subgroup of patients and requires further study. Possible reasons for low adoption of this parameter include the technical challenges inherent to performing this test, and the requirement of specialized ultrasound systems capable of performing Doppler and tissue Doppler measurements (which initial point of care ultrasound systems did not uniformly support). As the field of ultrasound continues to evolve from technological and pedagogical perspectives, a larger number of trained users will be equipped to implement the E/Ep and other advanced measures for the estimation of CVP.
Mechanically ventilated patients deserve special attention as they are a challenging subgroup of patients to study, and estimation of filling pressures is likely to be of great clinical relevance. In mechanically ventilated patients, the increased intrathoracic pressure exceeds intraabdominal pressures causing the IVC diameter to be larger than in spontaneously breathing patients. Despite this, the IVC diameter is still positively correlated with RAP (71). Moreover, insufflation during a passive mechanical ventilator-induced breath causes dilation rather than collapse of the IVC (71), rendering an opposite and less predictable correlation with RAP. In our study, the IVC diameter had the highest correlation and the narrowest CI of all the ultrasound measures evaluated, while IVC collapsibility had a reduced correlation with a wide CI, and the E/Ep had a non-significant correlation but included only 2 studies (44), Further study will be required before recommending IVC collapsibility or E/Ep in this group of patients.
Given the expanding interest and use of ultrasound by diverse practitioners, ultrasound-based assessment of CVP in no longer restricted to the cardiologist trained in echocardiography. Accordingly, the proportion of studies with non-traditional users was notable (30%). These studies generally focused on basic measures such as IVC diameter and reported correlation coefficients in line with those reported by traditional users. These data support the continued dissemination of echocardiographic training among non-traditional users in the intensive care unit, internal medicine, emergency medicine, and other fields.
Current guidelines from the ASE (72) are in line with the data currently covered in our systematic review and meta-analysis. Most of the studies included a dichotomization of CVP of > 10 mmHg corresponding with an IVC collapsibility > 40–50%. There was some discordance with IVC diameter, in that 3 out of 10 studies had significantly lower IVC diameter cut-off(17,25), but overall most studies had an IVC diameter corresponding to current recommendations.
First, the studies that were identified and reviewed evaluated the accuracy of ultrasound parameters in isolation and did not compare various combinations of parameters which may lead to greater diagnostic accuracy. Second, specific factors may interfere with the reliable use of IVC and right heart parameters as surrogates of CVP: these include tricuspid valve disease, etiology of right heart disease, pericardial disease, and atrial fibrillation. We could not determine presence or absence of these parameters from the published studies.
Finally, although it is important to understand how well ultrasound measures correlate to an invasive CVP, perhaps the more important question to be answered is how well ultrasound measures correlate to volume responsiveness.